Initial Comments:
A validation survey was conducted February 4-9, 2021, to determine compliance with the requirements of the 42 CFR Part 483, Subpart D Requirements for Emergency Preparedness in Psychiatric Residential Treatment Facilities. The census was seven individuals. There were no defciencies.
Plan of Correction:
Initial Comments:
A validation survey was conducted February 4-9, 2021, to determine the compliance with the requirements of 42 CFR Part 483, Subpart G Requirements for Psychiatric Residential Treatment Facilities. The census during the survey was seven and the sample consisted of five individuals.
Plan of Correction:
483.366 STANDARD
NOTIFICATION OF PARENT(S) OR LEGAL GUARDIAN
Name - Component - 00
If the resident is a minor as defined in this subpart:
483.366(a) The facility must notify the parent(s) or legal guardian(s) of the resident who has been restrained or placed in seclusion as soon as possible after the initiation of each emergency safety intervention.
Observations:
Based on a record review and interview, it was determined that the facility failed to ensure that a notification was made to the parent of a resident who has been restrained. This applied to two individuals (#1 & #2) in the survey sample that had been restrained. Findings included:
A record review for Individuals #1 and #2 was completed on February 8, 2021. This review revealed that both Individuals were restrained on November 11, 2020. This review failed to reveal documentation that the parents of Individuals #1 and #2 were notified of the restraints.
An interview was conducted with the director of residential services (DRS) on February 8, 2021, at 11:50 AM. The DRS confirmed that there is no documentation that Individual #1 or #2's parents were notified of the restraint on November 11, 2020.
Plan of Correction: In response to failure to notify parents/guardians as soon as possible, as found deficient in two records, the agency will review 100% of the restraints to ensure that the parents and guardians have been notified timely. The Service Coordinator will be responsible for reviewing this on a weekly basis. Additionally, this deficiently will be monitored through the Performance Improvement Council to ensure completion. This plan of correction will be begin on 3/1/2021 and will be until the agency feels confident that notification is occurring at all times following restraints.
The parents of the clients involved in the restraints were verbally notified of these restraints during the Treatment Team Meetings held on 11/27/20.
483.376(f) ELEMENT
EDUCATION AND TRAINING
Name - Component - 00
Staff must demonstrate their competencies as specified in paragraph (a) of this section on a semiannual basis and their competencies as specified in paragraph (b) of this section on an annual basis.
Observations:
Based on a review of staff training records, and interview, it was determined that the facility failed to ensure that all staff were trained and demonstrated competencies in safe crisis management on a semi annual basis for three of 22 staff training records reviewed. Findings included:
A review of facility provided staff training records was completed February 8, 2021. This review revealed that three of 22 staff on the facility roster were not trained in safe crisis management on a semi annual basis. Further review revealed that during this time frame these three staff did participate in restraints with residents.
An interview was conducted with the director of residential services (DRS) on February 8, 2021, at 11:50 AM. The DRS confirmed that the three staff were not current with SCM training, and further confirmed that the staff did participate in restraints.
Plan of Correction:In response to staff competency related to training and education, as found deficient in three staff records, the agency will ensure training is completed on a timely basis. This will be monitored by the Treatment Coordinator, as well as the Senior Treatment Coordinator, and will occur by supervisors running training compliance reports weekly to ensure staff are schedule timely for their training. Should a staff fall out of compliance with their training, they will not be permitted to participate in restraints until training as been completed. This plan of correction will be monitored through the Performance Improvement Council.
Of the three staff identified, two are no longer employed as of 2/5/21. The third is scheduled for training on 3/24 and has not and will not participate in restraints until training is complete.
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